MATTHEW BAGAN D.O., P.A.

COMPLETED IN FULL IN ORDER SERVICE

NAME (Last, First, M.I.)

Social Security #

Birthdate

M S W D SF Ethnicity/Race Sex

Marital Status

STREET ADDRESS

CITY STATE ZIP HOME PHONE CELL PHONE

EMPLOYER

OCCUPATION

BUS. PHONE

ADDRESS

EMPLOYER ADDRESS, CITY, STATE, ZIP

DRIVER LICENSE # STATE

NAME OF SPOUSE

BIRTHDATE

sS#

EMPLOYER ADDRESS

CITY, STATE, ZIP

BUS. PHONE

PERSON TO CONTACT IN AN EMERGENCY/RELATIONSHIP/PHONE

FAMILY PHYSICIAN GYNECOLOGIST REFERRED BY

PLEASE GIVE YOUR INSURANCE CARDS TO THE RECEPTIONIST FOR COPYING

FULL PAYMENT OR CO-PAYMENT IS DUE AT THE TIME OF OFFICE SERVICE CHECKS, VISA/MASTERCARD AND CASH ARE ACCEPTED

APPROPRIATE PAYMENT IS DUE AT THE TIME OF OFFICE SERVICE. NECESSA] .Y FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE PAYMENTS HOWEVER, T fE PATIENT IS RESPONSIBLE FOR PAYMENT ON THIS ACCOUNT REGARDLESS OF INSURANCE COVERAGE. IF NO PAYMENT IS RECEIVED FROM INSURANCE WITHIN 60 DAYS THE PATIENT S RESPONSIBLE FOR ALL CHARGES.

SIGNATURE DATE

• Musculoskeletal Muscle pain or cramps Yes No Stiffness/swelling joints Yes No Joint pain Yes No Trouble walking Yes No

*Hematological/ Lymphatic Bruise easily Yes No Slow to heal Yes No Enlarged glands Yes No

'Gastrointestinal Nausea Yes No Vomiting Yes No Abdominal pain, cramping Yes No Difficulty Swallowing Yes No Heartburn Yes No Loss of appetite Yes No Abdominal Bloating Yes No Reflux Yes No

Date:

• Eyes Wear glasses/contacts Blurred/double vision Eye disease or injury

Glaucoma

Yes No Yes No Yes No Yes No

*Cardiovascular Chest pain Palpitations Heart Trouble Swelling hands)

• Neurological Frequent head Paralysis or tr

• Psychiatric Insomnia

Confusionlm Depression

Rectal Pain Rectal bleedi Fecal Inconti Change in st Enlarged Her Diarrhea Constipation Black Stools

Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No

Yes No loss Yes No

Yes No

Yes No Yes No

ice Yes No shape Yes No rrhoids Yes No

Yes No Yes No Yes No

MATTHEW R. BAGAN, 0.0.: THIS FORM MUST BE COMPLETED IN FULL

PATIENT NAME:

REASON FOR YOUR VISIT:

Where on the body symptom occurs Duration: When did it start? How long does it last? Severity:

Symptom / pain scale 1-10

DOB: AGE: Height:

HISTORY OF PRESENT ILLNESS (HPI) Quality: Factoi Burning, gnawing, stabbing Things to make .s Timing: When it occurs; after meals or exercise, etc

Context: things that Situations associated with symptom

better or worse

when symptom occurs

Medical History: Please circle Yes or No if you have any of the following medical problems Diverticulosis... Yes No High Blood Pressure ........Yes No Diabetes .............Yes No Heart Trouble ..............Yes No Diverticulitis... Yes No Low Blood Pressure.........Yes No Kidney Disease......Yes No Cancer........................Yes No Colon Polyps ... Yes No Breathing Problems.........Yes No Stroke ...............Yes No Type: ________________ Ulcers ............Yes No Hepatitis.....................Yes No HIV/Aids............Yes No Joint Replacement ...... ..Yes No Bleeding .........Yes No Anemia.......................Yes No Frequent Infections Yes No Type:

Other Problems:

Current Medications

Blood —Thinning Medication, Coumadin, Plavix, Pradexa, Effient or Aspirin?

Drug Allergies: Drug:

Reaction:

Location:

Drug:

Reaction:

Location:

Severity:

Surgical History: Appendectomy NO YES YEAR: Gallbladder NO YES YEAR: Colon Surgery NO YES YEAR: Hysterectomy NO YES YEAR: Colonoscopy: NO YES YEAR: EGD (upper Endoscopy) Yes No Year: Mastectomy/Lumpectomy NO YES YEAR: Other:

Have you ever been advised to have any surgical procedure which was not done?

Stomach NO YES YEAR: Breast Biopsy NO YES YEAR:

YEAR:

Why?

Family History: Has any blood relative every had: Breast Cancer Yes No Who? Gallstones . . . Yes No Who? Colon Cancer Yes No Who? - Gastric Cancer Yes No Who? Other:

Social History: Marital Status: Occupation: Tobacco Use: I] Never LI] Quit/when C Current/pt -,ks per day

Alcohol Use: El Never C Rarely C Moderate LI] Daily Recreational Drug Use: C Never C Type & Frequenc

• Constitutional • Ears/Nose/Mouth/throat Good General Health Yes No Hearing loss or ringing Yes No Recent Weight Change Yes No Sinus problems Yes No Night sweats, fevers Yes No Nose Bleeds Yes No Fatigue Yes No Sore throat/voice change Yes No

• Respiratory • Integumentary (Skin / Breast) Shortness of breath Yes No Rashes or itching Yes No Cough Yes No Breast lump Yes No Wheezing/ Asthma Yes No Breast pain or discharge Yes No Coughing up blood Yes No Nipple Bleeding Yes No

•Allergic / Immunologic • Endocrine Food Allergies Yes No Excessive thirst/urination Yes No Aspirin Allergies Yes No Thyroid disease Yes No Antibiotic Allergies Yes No Hormone problem Yes No

• Genitourinary -Male Only • Genitourinary -Female Only Kidney Stones Yes No Kidney Stones Yes No Testicle pain Yes No Menstrual problems Yes No Straining to Urinate Yes No Straining to Urinate Yes No

Urinary Incontinence Yes No

Patient Signature:

Matthew R. Bagan D.O.

21st Century Oncology, LLC

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I hereby acknowledge: A copy of the Notice of Privacy Practices was given to me.

If I came in for healthcare services in an emergency treatment situation, I was given the Notice as soon as reasonably practicable after the emergency treatment situation.

Signature of Patient or Representative Date

Print Name

FOR OFFICE USE ONLY

If an acknowledgment is not obtained, please complete the information below:

Patients name:

Date of attempt to obtain acknowledgment:

Reason acknowledgment was not obtained: U Patient/family member received notice but refused to sign acknowledgment Li Emergency treatment situation U Patient was incapacitated and no family member was present Ci Unable to communicate due to language barriers U Other (please describe below)

Signature of Employee

085-Hi 8.2 03/26/2013

Assignment of Benefits/Right to Payment, Patient Responsibility and Release of Information Form

Matthew R. Bagan D.O. 21st Century Oncology, LLC P0 Box 862152 Orlando, FL 32886-2152

1, the undersigned, irrevocably assign to the provider/entity referenced above ("Provider"), all of my rights and benefits and any other interests that I have in any medical insurance plan, health benefit plan, indemnity plan, trust, fund or other source of payment for healthcare services (each a "Plan") in connection with medical services provided by Provider, its employees and agents. I understand that this document is a direct assignment of my rights and benefits under my Plan,

II instruct my insurance company to pay Provider directly for the professional or medical expense benefits payable to me. if my current policy prohibits direct payment to Provider, I instruct my insurance company to make out the check to me and mail it directly to the address of lockbox referenced above for the professional or medical expense benefits payable to me under my Plan as payment towards the total charges for the services rendered In addition, I agree and understand that any funds I receive by my insurance company due for services rendered by Provider will be immediately signed over and sent directly to Provider.

Patient Responsibility

I acknowledge and agree that! am responsible for all charges for services provided to me which are not covered by my Plan or for which I am responsible for payment under my Plan. To the extent no coverage exists under my Plan, I acknowledge that I am responsible for all charges for services provided and agree to pay all charges not covered by my Plan.

Release of Information

I authorize Provider and/or its agents to release any medical or other information about me in its possession to my Plan, the Social Security Administration, any state administrative agency, or their intermediaries or fiscal agents required or requested in connection with any claim for services rendered to me by Provider.

A photocopy of this Assignment shall be considered as effective and valid as the original.

Date: Signature of Patient'Person Legally Responsible

Print Name of Patient/Person Legally Responsible

Relationship to Patient (if signed by Person Legally Responsible)

73905$

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION (Policy 085-1-109)

I hereby authorize use or disclosure of the named individual's health information as described below. Patient Name Date of Birth Physician Location Acronym

Patient Address (Street, City, State, ZIP Code) Patient Telephone Number

The following individual or organization is authorized to make the disclosure: • 21st Century Oncology • Other (must be specific)

This information may be disclosed to and used by the following individual or organization (must include name and address)

Treatment Dates (if applicable) Purpose of Request:

The following information is to be disclosed: (check all that apply - must be specific) Yes No LI LI ........Consultation Reports o LI ......... Diagnostic Films o o Dosimetry Records LI LI ......... Laboratory Results LI LI ......... Physician Dictation o o ......... Portal Films/Simulation Films LI 0 ......... Progress Notes LI 0.........Radiology or imaging reports o o ......... Surgery/Pathology 0 0 ......... Complete record LI 0..........Other o o ......... Other

Sensitive Information: I understand that the information in my record may include information relating to sexually transmitted diseases, AIDS, or HIV infection. It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse. Right to Revoke: I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing to the Health Information Management Department. I understand that the revocation will not apply to information that has already been released based on this authorization Expiration: Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I do not specify an expiration date, event, or condition, this authorization will expire in one year. Redisciosure: I understand that any disclosure of information carries with it the potential for redisclosure and the information may not be protected by federal confidentiality rules. Other Rights: I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to ensure treatment. However, if this authorization is needed for participation in a research study, my enrollment in the research study may be denied.

I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524.

If I have any questions about disclosure of my health information, I can contact the 21st Century Oncology Privacy Officer at (866) 679-8944. Signature of Patient or Legal Representative Date

If Signed by Legal Representative, Relationship to Patient

085-H09. 1

Use this form during patient registration to document any patient requests to authorize and restrict how their health information is disclosed to friends/family members/others. Use also to document any requests for

confidential communications.

Patient Authorization for General Disclosure and/or Request for Restrictions of Protected Health Information

and Request for Confidential Communications

I hereby request the following use or disclosure of my health information as described below. Patient Name Date of Birth Medical Record Number

Address (Street, City, State, ZIP Code) Telephone Number

I request that my health information or medical billing record be disclosed or restricted, as follows.

I authorize the names listed below to have access to my medical Information. These people may call and speak with the nurse/doctor about my case. I have the right to terminate this agreement at any *DO NOT discuss or provide information to the following individuals time by informing a representative of the physician office or entities:

Authorized Name Relationship to Patient Restricted Name/Entity Relationship to Patient

*1 request the use of ONLY the following address and/or phone number(s) to contact me regarding my health or billing information:

Patient Rights: Your physician office must permit patients to request restrictions of their protected health information Patients may request restriction of uses and disclosures of protected health information to carry out treatment, payment, and healthcare operations; disclosures to a family member, other relative, close personal friend, or any other person identified by the patient of protected health information directly relevant to such person's involvement with the patient's care; and disclosures of protected health information to notify or assist in the notification of a family member, a personal representative, or another person responsible for the care of the patient of the patient's location, general condition, or death. All requests for restrictions must be submitted in writing

Physician Office Responsibilities: Your physician office is not required to grant most restrictions and is precluded from granting restrictions that would violate the law. If we agree to the restriction, we will comply with it unless you ask to terminate the restriction or we notify you that we are terminating the agreement If you require emergency treatment, we may release the restricted information without your consent if it is needed to provide that treatment. Signature of Patient or Legal Representative Date

If Signed by Legal Representative, Relationship to Patient

THIS BE BY PHYSICIAN OFFICE PERSONNEL ONLY

DISPOSITION of PATIENT REQUEST: The above request for restriction of health information by the above-named patient has been:

*Granted Denied

*If GRANTED, an Alert must be entered into all electronic medical records and/or practice management (billing) system(s)

Reason(s) for Denial, if Applicable

Physician Office Representative. Date.

085-Hi 7.1 02/01/2012

Notice of Privacy Practices Matthew R. Bagan D.O. 21 s Century Oncology, LLC

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED I AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. _J

Each time you visit our physicians or receive treatment from us, a record of your visit is made. This record may contain your symptoms, examination and test results, diagnoses, treatment. a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by your physician.

Our Responsibilities We are required by law to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to that protected health information, and to notify any affected individuals following a breach of any unsecured protected health information. We will abide by the terms of the notice currently in effect.

Uses and Disclosures - How we may use and disclose protected health Information about you

For Treatment: We may use protected health information about you to provide you with treatment or services. We may disclose protected health information about you to doctors, nurses, or other personnel who are involved in taking care of you, For example, we may need to communicate with your primary care doctor to plan your treatment and followup care.

For Payment: We may use arid disclose protected health information about your treatment and services to bill and collect payment from you, your insurance company, or a third-party payer. For example, we may need to give your insurance company information about your diagnosis so that it will pay us or reimburse you for the treatment.

For Healthcare Operations: We may use or disclose, as needed, your protected health information in order to run our practice For example. members of the medical staff and/or quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it The results will then he used to continually improve the quality of care for all patients we serve.

We may also use and disclose protected health information: • To business associates we have contracted with to perform an agreed.upon service • To remind you that you have an appointment for medical care • To assess your satisfaction with our services • To inform you about possible treatment alternatives • To inform you about health-related benefits or services • To conduct case management or care coordination activities • To contact you as part of our fundraising efforts, if any, though you will have the right to opt out of such communications • To inform funeral directors consistent with applicable law • For population-based activities relating to improving health or reducing healthcare costs • For conducting training programs or reviewing competence of healthcare professionals

Individuals Involved in Your Care or Payment for Your Care' We may release protected health information about you to a friend or family member who is involved in your medical care or who helps pay for your care.

Research' We may disclose information to researchers when an institutional review board has approved the disclosure based on adequate safeguards to ensure the privacy of your health information arid as otherwise allowed bylaw,

Future Communications We may communicate with you via newsletters, mailings, or other means regarding treatment options, health-related information, disease management programs, wellness programs, or other community-based initiatives or activities in which our facility is Participating,

As Required by Law, we may also disclose health information to the following types of entities, including but not limited to: • The 'U.S. Food and Drug Adnrirustrationm • Pubic health or legal authorities charged with preventing or controlling disease, injury, disability, or other threat to health or safety • Correctional institutions (if you are in custody of a correctional institution or a law enforcement officer) • Workers' compensation agents • Organ and tissue donation organizations • Military command authorities • Health oversight agencies • Funeral directors, coroners, and medical examiners • National security and intelligence agencies • Protective services for the president and others

Law Enforcement / Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.

085H 18.1 03/2612013

Notice of Privacy Practices (Page 2) Matthew R. Bagan D.O. 21st Century Oncology, LLC

Other Uses of Your Protected Health Information That Require Your Authorization Uses end disclosures of your protected health information that involve the release of psychotherapy notes fit any), marketing, sale of your protected health information, or other uses and disclosures not described in this notice or required by law will be made only with your separate written permission. If you give us permission to use or disclose protected health information about YOU, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Your Health Information Rights Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the right to

• Inspect and copy protected health information. You may request access to your records by contacting us. You may also ask that we send your health information directly to another person based on your signed written instructions. We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to protected health information, you may request that the denial be reviewed in some situations Another licensed healthcare professional chosen by us will review your request and the deniaL The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. We reserve the right to charge you a reasonable tee to cover the cost of providing you with a copy of your records.

• Request an amendment. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information by making a request in writing that explains the reason for the requested amendment. You have the right to request an amendment for as long as the information is kept for or by us. We may deny your request for an amendment: if this occurs, you will be notified of the reason for the denial.

• Request an accounting of disclosures. This is a list of certain disclosures we make of your protected health information for purposes other than treatment, payment, healthcare operations, or certain other permitted purposes.

• Request restrictions or limitations on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we riot use or disclose information about a surgery you had. We are not required to agree to your request., except as described below If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment If you ask us not to disclose your health information to your health plan, we will agree as long as (i) the disclosure Would be for the purpose of payment or health care operations and is not otherwise required by law and (ii) the information only relates to items or services that someone other than your health plan has paid for in full,

• Request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example. you may ask that we contact you at work or by U.S mail. We will grant requests for confidential communications at alternative locations and/or via alternative means only if the request is submitted in writing and the written request includes a mailing address Where you will receive bills for services rendered by the facility and related correspondence regarding payment for services, Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response

• A paper copy of this notice. You may ask us to give you a copy of this notice at any linac. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our Web site at w'w.21 stcentoryoncology corn

Changes to This Notice We reserve the right to change this notice: the revised notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will he posted in the facility and will include the new effective date. Copies of any revised notices will be available on our website and will he provided to you upon your next visit to our facility after the effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Officer toll free at 1-866-679- 8944, or by contacting the Secretary of the U.S. Department of Health and Human Services

You will not be penalized for filing a complaint.

For further information, contact: Privacy Officer 2270 Colonial Boulevard Fort Myers, FL 33907 I 8666798944

0854118.1 03/26/2013